Authorization for Release of Information

Your Rights with Respect to this Authorization Right to inspect or copy the health information to be used or disclosed – I understand that I have the right to inspect or copy the health information I have authorized to be used or disclosed by this release form. Right to receive a copy of this release–I understand that if I agree to sign this authorization, which I am not required to do, I will be provided with a signed copy of this form upon request. Right to withdraw this authorization–I understand written notification is necessary to cancel this authorization. I am aware that my withdrawal will not be effective as to uses and/or disclosures of my health information that the entity(s) listed above have already made in reference to this authorization. Right to refuse to sign this authorization–I understand that I am under no obligation to sign this form and that the entity(s) listed above may not condition treatment, payment, enrollment in a health plan or eligibility for health care benefits based on my decision to sign this authorization Expiration date–This authorization is good for 1 year from the dated signed. I have had an opportunity to review and understand the content of this authorization form. By signing this authorization, I am confirming that it accurately reflects my wishes.

By signing this form, I hereby authorize ST CROIX THERAPY, INC. (742 Sterbenz Dr Hudson, WI 54016) to Obtain and/or Release information to the entities/person(s) listed.